Tragedy and Hope Wrapped in a Medical Mystery: Abraham Verghese and 'The Covenant of Water'

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol for the Medscape Medicine and the Machine podcast. Today, we have a unique combined podcast with my friend Bob Harrington and The Bob Harrington Show because we are going to interview Abraham Verghese about his new book, I would say masterpiece, The Covenant of Water. We are thrilled to have you, Abraham.

Abraham Verghese, MD: It's a strange position to be in, Eric. I'm usually your co-host and now I find myself to be the subject. But what a delight. Thank you so much.

Topol: Bob, why don't you get things started? I have a long list of questions.

Robert A. Harrington, MD: Abraham, thank goodness I had a couple of cross-country trips during which I was able to read through the book and appreciate its beauty. First, I want to thank you and Eric for having me on your podcast, because this will hopefully raise the ratings of my podcast. Thank you both.

Can I begin near the end? I'm not going to do a reveal, but I want to talk about the medical problem that moves through the generations of characters. Was this something you had seen as a student or something you had read about? I was fascinated by how it all plays out.

Verghese: Much like you and Eric, I have a few zebras that I tuck into my back pocket. And every now and then, when I run out of things to talk about on rounds, I'll ask a question like this: Why do we say beware of a man with a giant liver and jaundice and a glass eye? Little riddles and puzzles. One of the puzzles I have always used was about familial drowning. The residents' immediate reaction is to talk about cardiac causes and channel disorders. But one of the other possibilities is the one I have in the novel, which is not a cardiac disorder. I've been fascinated by the fact that over many decades, there are conditions that are labeled but that's about it. Then decades pass before we truly understand what these conditions were.

A great example is that people have known about jaundice for years, and they recognized that when you had jaundice, your urine turned a deep yellow. But they also recognized that there was a kind of jaundice that ran in families and the urine did not turn deep yellow. They called this acholuric jaundice: jaundice without bile in the urine. Many decades later, we now know they were talking about hereditary spherocytosis.

I've always loved that sense that we're probably dealing with things now that in 90 years, will have clear labels and make us look like primitives in retrospect. I wanted something like that to play out in this novel, which is why it had to include several generations.

Topol: The thing that struck me the most, and I'm interested to get your perspective, is the impact of your mother in this book, not only about when she responded to your niece with the long manuscript and the sketches she put together, but the names you used in the book: Big Ammachi and her granddaughter, Mariamma. It seems that your mother's influence was profound. Can you speak to that?

Verghese: My mother's influence was really profound. As you mentioned, when she was in her seventies, she penned a manuscript for my niece, who was 5 years old at the time, because my niece asked her what it was like when she was a little girl. My mom was floored by the question. How does she communicate to a 5-year-old girl what her own 5-year-old existence was like? She was born in the 1920s, with no running water or lights. It was still true when I went to visit in the summers, and it wasn't a deprivation. Far from it. It was beautiful, with ghostly-lit evenings that were quite special. The harsh electric light kind of destroyed the mood.

My mom graduated with a degree in physics just about the time India was getting independence. There were no jobs to be had then. She saw an ad for a teaching position in Africa. Can you imagine a woman, a single woman in a sari in the 1940s, taking a steamer to Aden and then to Ethiopia? Sight unseen. She clearly had a tremendously daring spirit. Then in her fifties, she came to America and taught junior high. She came here long before I did. So by her seventies, she had lived through so much. And she began to write this document, handwritten and illustrated, for my niece. That document was a great inspiration for me to set the novel in Kerala, India. Geography is perhaps the biggest decision you make as a novelist. Where are you going to set this story? If I tried to set the same story in Pasadena, it would alter the story completely. So that was huge.

But to be honest, more than my mother, I was celebrating my grandmother and my great-grandmother by reputation in this story. In many novels, mothers are portrayed as evil or flawed. My grandmother left her home as a young bride, married to a groom who was just as young as she was. It always startles the Western reader about a 12-year-old girl getting married. But for the most part, they were marrying 12-year-old or 10-year-old boys, and they just became children in their husband's household. In fact, on the tour, I ran into a relative who was showing me some photo albums and pointed to one of my relatives who is long deceased. Their bond with their mother-in-law becomes greater than with their mother because they come to this new house at the age of 10 years. This little girl said to her mother-in-law, "See that boy, that annoying fellow, that one over there, can we get rid of him?" And that was her husband.

My grandmother lived her life in that compound. I don't think she ever left the place, had no real knowledge of the outside world except from what she read in the paper. She could read. But she lived a heroic, beautiful life in the confines of that compound and the influence she had on her family and the love she gave her children. So I was trying to celebrate that kind of quiet heroism, the steadiness, showing up every day, and the faith in small things that isn't featured enough. It's been curious that the book has had a wonderful reception and people are recognizing that quality, that sense that you can be unknown to the world and yet you can be heroic and special. I think that's why people are responding beyond any dreams I had for the book.

Harrington: Abraham, let me extend the question Eric asked you about your mother and her influence. Your answer is about paying homage to strong women in your life. How does a male author tap into these feminine qualities, which you explore so beautifully? I felt like I was listening to my own mother and grandmother, and then I remembered that this is a male author writing about this. How did you do that? What was the process?

Verghese: I had a great deal of help from my mother. She lived long enough to be of great help to me. As I was writing this, she would tell me different anecdotes, and some of which were very much from a woman's point of view; things I would not have thought about. I interviewed many of my cousins and aunts in great detail, and I was humbled by it. I had no idea, for example, how much women were harassed when they went to the big city, how much that everyday teasing made life a nuisance for them. The nuances of childbirth. I would have had no idea about that except from debriefing my cousins about that whole experience and the sense of being completely isolated in this other world, and no one could help you. So I had a lot of help and when I didn't have help, I had my imagination.

Topol: Speaking of imagination, you went from 1900 all the way up through the 1970s. So you had to describe not only the geography that perhaps you are only familiar with from summers with your grandparents or the medical school in Madras, on the other side of the country but also the history. You attended to details and accuracy. How were you able to take us back in time like that?

Verghese: First of all, it was a lot of fun because that was an incredibly important epoch in human history. Two world wars, and within India, you had this major upheaval after centuries of colonization. Finally, in the 1940s, you have the country becoming independent. That is a very interesting and well-known time period to write about. I had a couple of spreadsheets going with all the medical advances year by year from 1900 to 1977, and then the political changes in India, the world, and global changes year by year. I was always careful to make sure that the local events I was describing were accurate. For example, if someone were listening to a radio, they were listening to something that could have been happening at that moment.

But there's a point when research just becomes an excuse not to write. So I did a lot of research, and I went back to India a couple of times, and I was quite familiar with the area. We spent 2 months in the summer there every year. Even though I'm not fluent in reading or writing Malayalam, the local language, I understand it pretty well. It wasn't like a foreigner going there to write a story and set it there. I had some familiarity with the rituals. But there comes a point when you have to say you have enough material and you just go with it. I had a lot of great researchers helping me as I got into the novel; people in Kerala who were translators from Malayalam to English who had a great understanding of what I was trying to get at and made sure I got it correctly. So it was a lot of fun. I think if I picked 1800-1900, it would have been much harder to research.

Harrington: I love the quote "Research just becomes an excuse for not writing" I'll remember that when I'm writing my own papers. I'm looking behind you now, and I can see your whiteboard. Talk about that process. How does that work for you? Does it stimulate your imagination? Is that how you explore an idea?

Verghese: The genesis of this whiteboard is that my first book, My Own Country, took me 4 years. The next one, The Tennis Partner, took me 6 years. Cutting for Stone took me 8 years. I'm not very good at math, but I could see the trend was not in the direction I wanted. So I was determined to do my best to plot out this novel. That's hard to do. How do you plot out an entire novel when you haven't begun writing it? But I had the geography, I had three generations of this family, I had the principal character, the protagonist. So I began to draw this elaborate whiteboard.

I do think visually, so it was very helpful. But soon, I was deviating from the whiteboard, and I had to stop, photograph it, erase it, and start again. There's a dictum in writing that character is determined by decisions taken under pressure. In other words, you can describe a character and talk about their habits and this and that, but it's only when you put that character under pressure that you see who they are. So I would put my characters under pressure, and next thing I know, they would do something entirely different from what I had in mind, and I'd be forced to change the whole direction of the plot.

I have had a lot of conversations about structure with other writers. John Irving, who is a friend and mentor, says that you have to know the whole story. And he does. He knows the last line and the first line of the book he's writing; he knows the ending and beginning of every chapter. And he said, "Abraham, if you don't know what you're hiding under the table and when you're going to bring it out, then you're not a writer. You're just an ordinary liar. You're just making this up as you go along." I told Michael Ondaatje this anecdote, and he said, "You know, I know where John's coming from, but it's hard to get there."

I think eventually, writers like me get to the point where John is, in the sense that at a certain point, after all these iterations of the whiteboard, I knew the whole story. And once I knew that, then I could go back and make sure things connected and what needed to be hidden was hidden and that I left enough clues. So that's a very satisfying moment when you get there. But for me, it came after years of writing, years of finding out that this vein was not the right vein to pursue or that that vein was fruitful but not for this book. It's hard, but I don't know any other way. I have to find a more efficient way, but it eludes me right now.

Topol: Seems that it worked for you pretty darn well. I read Andrew Solomon's review of your book in The New York Times, where he quite appropriately described you as a genuine humanist and discussed your ability, your expertise, and profound moral architecture of the spirit. He suggested in that piece that your inspirational storytelling was like Charles Dickens. Were you inspired by Charles Dickens?

Verghese: It would be hard not to be inspired by Dickens. Growing up, I was an ardent reader, like both of you. I know Bob is very much of that mold. I read all the classics, and Dickens was the consummate storyteller. The way he built the character: Who can forget Uriah Heep or David Copperfield or any of his characters? They live. I believe I was very much influenced by Dickens, but perhaps more than Dickens, my big influences were more recent. Gabriel Garcia Marquez: I just love his brand of storytelling and his prose, which is a little more lyrical, more poetic than is Dickens, whose writing is colorful and breathtaking.

We're always standing on the shoulders of giants, and in that sense, it is much like medicine. Little that we do is completely original; everything we do is based on very good knowledge of what has come before. You have to know what's there before you can get to the next level. It's striking to me the number of writers who are doctors. They're good at what they do in medicine, sometimes they have very senior administrative posts, and then they decide they want to write a novel, which often turns out to be a thinly disguised fictional version of their own lives. They feel no compunction to have read anything in literature. So there's a great deal of hubris. When you read great writers, you're humbled, and you know what the standard is. And, by God, it takes a lot of work to build on that. That's what you're trying to do.

Harrington: One of the great joys of my life, Eric, is that I get to run into Abraham in our office suite here; our offices are next door to each other. I remember when I first arrived at Stanford, I came home after work one day, and our daughters were home from college. One of them asked, "So, Dad, how was your day?" I said, "Okay, you tell me how my day was. I popped into Abraham Verghese's office, and we talked about what books we're reading for a half hour." For a chair of medicine, that's a pretty good day.

But I like this notion, Abraham, that in order to write, you need to read, and you need to have read deeply and broadly. You certainly have helped me with that. Throughout the book, there are some great quotes that I've heard you use over the years: "Fiction is the great lie" and "standing on the shoulders of giants." I'm trying to get at your process. Have these phrases become ingrained into your conversational vocabulary? Or are they sayings you write down when they catch your imagination and you think, Huh, I might use this at some point?

Verghese: Yes, I do that. Some are things I've heard and latched onto. For example, the phrase "God is in the details." I heard that in my residency in America, but I also heard it at the Iowa Writers Workshop. It's amazing how certain phrases are common to many different trades. The business about fiction being the great lie that tells the truth has always resonated for me because I feel like I'm always trying to make the case as to why we read fiction. There's a trend, especially in medicine and science, for people to believe that if I'm a serious kind of guy, then I only read biographies and memoirs. I don't read fiction. It's somehow beneath me. This always surprises me because we are brought up reading stories. We raise our children and our grandchildren reading stories to them. This is essentially how we teach children about the wider world. And to abandon this practice when you become of age seems to be premature.

I also believe that, as surrounded as we are by visual things — video and movies, and I don't knock any of them — there is something about the exercise of taking the digital signals we call words on a page and turning them into a mental movie in your head. The process of writing a book is ultimately a collaborative act with one reader. In my mind, the writer provides the words, the reader provides their imagination, and somewhere in the middle space, this mental movie begins to take shape, and it's very much the reader's. This is why when readers see the movie, they're terribly disappointed if so-and-so has been cast as the lead when they visualized it another way. I worry that if we don't have this exercise of reading words and making our mental movies, a part of our brain atrophies.

I relate it to a kind of unimaginativeness in medicine. I don't mean in terms of inventions. But, if you think about it, the number of colorful metaphors, like the saber shin tibia, the mulberry molar, the salt and pepper skull, the strawberry tongue... I can't point to a metaphor within the past 50 years as colorful as the peg-shaped incisor. It's striking because in my lifetime, I've seen so many new diseases in my specialty —- AIDS, SARS, Lyme, ehrlichiosis, and on and on, but not one new metaphor. This is partly because we have become so rigidly left-brain focused that we're not being as colorful and imaginative with science as we can and should be in order to communicate it well to other people.

Topol: That is interesting and insightful about metaphors. You spoke about the written word, but you also read the audiobook. How many weeks did it take [to record]? Of course, you have a wonderful voice which is why doing the podcast with you is a treat because of your soothing, deep, impactful voice. What was it like to read the book? You're giving the audio signals rather than the written ones for people to use to make their mental movies.

Verghese: It was a learning experience. I had a strange experience with Cutting for Stone. The audio was well-liked by the public. The guy won awards, and I got to meet him. He's a young Indian actor who grew up in America. But I had problems with some of his pronunciation, and it turned out, I was the only one who had problems. So I decided to audition for reading this book.

People are surprised: Why do you have to audition? You wrote the book. In fact, it's a red flag when authors read their own books, in general, because to read a novel, you have to perform the novel, and it's not a given that a writer will be able to perform their own novel. I had to learn how to change my pitch so that listeners can tell one gender from another, and how to do accents, but not overdo them. I had to practice a Glaswegian accent, a Geordie from Newcastle, upper-crust British; Tamilian; Madrasi; and Malayali. It was a lot of fun. It took 3 weeks to record. But in doing that and reading it aloud, even though I knew the story so well, it was still emotional for me, for the technician, for the producer, and the director. I also began to see connections that, I swear to God, I never put in there.

It was revealing to me; almost like the subconscious mind is doing things. You don't necessarily see them as you're writing, but later on, you appreciate that they are there. It was almost eerie but quite beautiful. Audiobooks are very AI driven. They take out stomach noises, lip smacks, etc. They make you redo a lot, but the technology allows you to redo it smoothly so you can just pick up in mid-sentence. Even so, when I heard it, I was disappointed. None of us like the sound of our own voice when we hear it outside our head. We're used to this echo chamber that we live in.

It's been gratifying to see, for the most part, that people are enjoying the audio as much as the printed book. They're rating it well, which is delightful. I always have read my work out loud or had someone read it to me in order to understand how it sounded. Later, I began to listen to more and more audiobooks. At first, I resisted. I was a purist. It had to be on the page. I couldn't be listening to the book. But up to 30% of readers are not reading. They're listening. And if you're a good writer, you're always reading the work aloud because the assonance could be off, and you won't know it until you hear it. There could be a false rhyme that you didn't intend to put in. It's been an interesting, awakening experience to record this book.

Topol: I auditioned to read one of my books and flunked.

Harrington: One of my favorite characters in your book was Digby. As the young son of a single mother, that's my life story. I was very attracted to him and his ability to rise above some incredibly difficult situations that occur over and over throughout his life. He is an incredibly noble character. Can you give me a little bit of his voice? A little bit of his accent? I loved hearing him.

Verghese: Were you listening to it or were you reading the book?

Harrington: I always read, but however my brain works, I hear the words when I'm reading.

Verghese: If you listen to the audiobook, you'll find the purists will tell you that this is not a pure Scottish accent, it's more Irish. But that also is not wrong because he's a Catholic of Irish ancestry. So it would be like, "Matron, do we really have to put this person under anesthesia for this?"

You and Eric will appreciate this: At one point in the audio recording, there was a phrase, a Glaswegian proverb or something. And the way it was spelled and the way I had to say it. I just couldn't find the right connection. So I called Euan Ashley. Perhaps you know him. He's a cardiologist who's doing all this cutting-edge genetic research. I said, Euan I'm going to send you this message by text and I want you to read it back into your phone, record it, and send it to me. He must have wondered, what is this about? But he has such a beautiful Glaswegian accent. Then I played that back about 20 times, and I delivered as best I could.

Harrington: Fantastic.

Topol: It really is a commitment to quality and accuracy. Now, one of the striking outgrowths of this book is how it was viewed by Oprah as one of the top three books that she's read in her life. Then you sat with her on a memorable television segment. I was blown away. I'm sure Bob was as well. She wants to make a movie of the book.

So tell us, what was it like to have Oprah's backing? It's so extraordinary, the experience you had with her.

Verghese: It really is extraordinary. I don't know what to say. I knew about a month before the announcement that she had picked the book because I got a call out of the blue. I was expecting a call from my publisher, but it wasn't from my publisher. It was from Oprah. She has a distinctive voice, but it took me a long time to believe it was actually her. I kept questioning her. She told me later that she decided to just launch into the book. She had read that book inside and out, and she'd gone back and read my other books. She looked up papers about me. People assume that she has producers doing all this for her, but I think the key to her success is when she takes on something she knows it cold. We had the most wonderful 40-minute dialogue. I never saw it coming.

I thought Cutting for Stone would be a book that she would pick. It had elements that I thought would she would like. Later, she said, "I don't know that I would have picked that book. I was doing so many shows back to back that my attention span was this long. I'm not sure I was ready for that book." But, she said, "You're a different writer now. You're a better writer. I'm ready for the message in this book." When she began reading The Covenant of Water, she knew this was the book a couple of pages in.

It's been a phenomenon on the book tour. I don't want to sound like I'm making too much of this, but I don't understand it myself. People are having this great reaction, this connection with these simple characters who are bringing something out of them about themselves and about the unheralded people in their lives, perhaps. I don't quite know.

I shared with Bob that it would potentially be the most nerve-wracking moment of a person's life to appear on the CBS Morning News with Oprah and Gayle. It was just after I met her and I was getting on stage, I felt this enormous calmness. I was not nervous at all. I think it was a sense that all the dues I've paid, and Bob knows how many ups and downs I've had with this book, that for once I wasn't like, Oh, shucks, do I deserve this? I felt like I belonged there. This was my moment and I wasn't going to waste it by being overly humble. Not that I was arrogant, but you know what I'm trying to say? It was my moment and I sort of knew it and felt deserving for the effort I put into the book.

Harrington: Abraham, let's talk about the book tour, since we're talking about Oprah. You say that people have appreciated the simplicity of simple people doing extraordinary things. To me, none of these were simple people. These were deep, complex, and many times conflicted individuals. What are you experiencing on tour? What are people talking with you about? What's moved them and what's moved you, from talking to your reading audience?

Verghese: I think you're right. They're not all simple people. When I say that, I'm referring to Big Ammachi. She's the main character, and for the longest time I've been saying that I didn't have any thesis in mind. I wasn't proselytizing. My goal is always a good story well told. But the truth is, when I look back now, I'm seeing a pattern. I think they are good people who make bad decisions and then are trying to atone. They're trying to make up for it. And that's me. I suppose that was me coming through, the sense of being able to see the mistakes I've made and wanting to atone for them, to make them whole. There's a part of me in many of those characters, like Digby and Philipose.

Because of Cutting for Stone, I have a reader base. But with Oprah's enthusiasm, we sold out all the venues on the tour. There were places people couldn't get in. The other phenomenon, which was wonderful, was that so many young doctors showed up. They look incredibly young, but they're already neurologists. They're attendings. But to me, they look like babies. They tell me that one or another of my books was deeply meaningful to them. And boy, that tops any sort of prize that one can get. So that was huge.

Most of the time, you do a tour to generate PR, to support the independent bookstore, and to sell the books. In a funny way, we were starting backward because the book was already flying off the shelves. All the indie bookstores were already getting a lot of attention and the audience could not be fulfilled. I was going to each place and on one level, I didn't need to go, but I needed to go in the sense that I love to support indie bookstores. These people wanted to come to see me, but it wasn't just to see me. They were rallying around this thing I represent. I don't quite know what it is, but it was beautiful. It was just like a big love fest.

I have to give a shout out to Stanford. This is not self-serving because my boss is here, but do you know how many universities will back someone like me, and allow me to have this aspect of my life? It's a long-term investment. It has been 10 years and now it's bringing to Stanford, I hope, the kind of acclaim that it deserves for their support. I've been quite lucky. I'm praying every night, counting my blessings, full of gratitude for everything that's happened in the past 10 years or more.

Topol: I posed a question earlier about the accuracy across many decades before you lived on this earth. In the same vein, you're not a surgeon. Yet you wrote about surgery — whether it's neurosurgery or hand surgery or a C-section — as if you were a surgeon. How did you do that?

Verghese: Surgery is inherently full of drama, much more than an abstract discussion of endocarditis, for example, which I could write about fairly easily. Also, I was always enamored a bit by surgery. When I was an intern in India, you couldn't get your degree till you did a 3-month internship in everything. As a medical student, a surgeon had taken me under his wing: a professor, a great teacher. He thought I was going to be a surgeon, and I probably thought so too. I got to do a lot of stuff with him. Then, at the end of the 3 months of internship, I got to do a gastrojejunostomy on my last day. They did the vagotomy part, but I did the rest ,and it's a heady feeling that I never forgot.

I love internal medicine, but I love surgery just about equally. Coming to America, I believed that medicine was the way to go. If you remember, in those days, surgery residencies were all pyramidal programs where they famously took foreign graduates and spat them out after 2 or 3 years. I didn't want to take that chance. You never got to be chief resident. I loved internal medicine more, perhaps, although at the time I could have gone either way.

But I always had some regret about turning my back on a field that was inherently so dramatic. I have a lot of surgeon buddies, and I hang around with them. Pretty much for all the operations described in this novel, I watched them more than a couple of times and even got to retract and whatnot. So, yeah, it's fun writing about it.

Harrington: Eric, I know one of the reasons you've done these podcasts with Abraham is to think about the humanity in medicine that can be missing. You've written eloquently about that.

Topol: You're too kind, Bob. One thing I would say is that my friendship with Abraham over this past decade has brought out the humanistic qualities and a much deeper sense of humanity. I think the book exudes that. You've had a big influence on me, Abraham, and I know on Bob, and everyone you touch. By the time this book gets around over the years ahead, you will have touched millions of people. Just like Cutting for Stone. How many books have a million-plus copies out there? And this one will, too. Congratulations. We're going to talk to you more about the book, of course, over the years ahead.

This has been fun. It's a rare opportunity to turn the table around and get some of your inner thoughts about this masterwork. It's an extraordinary experience just to go through it and to learn about the condition that you somehow discovered to lace the generations together, the evolution of modern medicine, and these characters that you inevitably love, and somehow you bring hope into tragedy.

Verghese: I must say, I felt very good about the medical profession at the end of my book tour. I've always felt that medicine was a romantic and passionate pursuit, a calling. And the 10%-15% of people who were showing up were physicians who felt that way too. Yes, they're stressed out, and they're burnt out, and they want to talk about it. But boy, their hearts are in the right place. What a privilege it is, for all three of us, to be the age we are and to be looked up to at times and to feel that people are responding to some of the principles we hold dear — to find that they count on us, in a sense, to articulate those principles and to stick by them. You and Bob have been courageous in the things you've stood up for, not always the most popular things. But we've got to do the right thing. My sentiment from the past 3 weeks is that doctors want to do the right thing. We're on track.

Harrington: It would be tough to top that. Abraham, I'll just say thank you. It's a privilege to have read your book. As Eric said, it brings out the themes that have made literature great. Going back to the Greek and Roman writers, you've taken tragedy and showed us hope. You've connected people who we can connect with. I know the amount of work that went into this book, which made it even more special because I appreciated the work you poured into this over the course of the last decade. Having said that, I hope the next one doesn't take another decade, and that Eric and I can have you back for another discussion. Eric, thank you so much for letting me join you on your podcast. This has been a lot of fun.

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Cite this: Tragedy and Hope Wrapped in a Medical Mystery: Abraham Verghese and 'The Covenant of Water' - Medscape - Jun 07, 2023.